A labour of love

Last weekend, I was sitting in a restaurant in Petionville, having a late dinner. We were too lazy to cook, and hadn’t been grocery shopping recently anyway. There is a place that makes really excellent
fresh Italian pasta (the owner is from Rome).

We had finished eating when the guy tending the bar approached our table. He was smiling broadly. He showed me a studio photograph of a plump, healthy infant. He said, do you remember this baby?

I said, I’m sorry, she is lovely, but I have no idea who this is.

He said, don’t you remember October 31st?

I apologized again. I really didn’t remember. I felt badly because he was standing there, still smiling expectantly. And clearly a proud father.

But come on. We deliver a thousand babies a month, on average. In October, it was about 1600. I can’t remember them all!

Then he said, she was born in the intersection. You pulled her out of the car, and I walked with you to the hospital.

Dans le carrefour. Yes, I do remember this child! Of course! From a car in the middle of the intersection, after wading through traffic. The car broke down, he said. Her mother delivered in the back seat.

It is so satisfying to see a Jude Anne baby later, doing well. In October, we were in full assembly line mode because it was so busy. Sometimes we forget that they grow and develop and have futures,
because we aren’t there to follow it. But of course, they do. And the parents don’t forget.

Despite the fact that, while we were moving, patients were not arriving on our doorstep and the other maternities in the city were able to absorb the increased patient numbers which included transfers
from us… despite that, we are again in a situation of being alone in our ability to function.

The general hospital doesn/t have surgical linen packs (sterile field, surgical gowns). They used them all today and they haven?t circulated out of sterilization yet. The maternity at Issaie Jeanty has multiple problems, including lack of gauze, lack of gasoline, etc., that led them to close their doors (‘fermer la garde’). Choscal, in Cité Soleil, doesn’t have a gynecologist; maybe one will come at 7 or 8pm. Hopital de la Paix has no water.

We have just rewritten our admission criteria. The idea is to really focus ourselves on the sickest, most critical patients. We want to save lives! But what is the point of new admission criteria if we
cannot apply them? It seems for many women, the choice is for us to keep them or for them to labour at home.

It is extremely frustrating. In particular, it?s frustrating because it’s a chronic problem. Also because it seems there?s little we can do about it, except discuss and object and advocate.

I need a new index. (Floor delivery index these days is usually zero. One on Thursday) Maybe NFI Non-Functionality Index. Number of days a month that a hospital cannot take transfers. Also cNFI: continuous Non-Functionality Index, for number of consecutive days.

Most days I love my job but today was not exactly a highlight.

Rounded this morning on antenatal ward, as usual. The first patient took us a long time to discuss: she has severe pre-eclampsia, and intra-uterine growth restriction, and appeared to have some ascites and some dyspnea. She was apparently well in the morning, had breakfast, and had just received her dose of magnesium sulphate. We saw her somnolent and floppy, complaining of being hot.

Unfortunately, it is not common practice here to check and follow patellar reflexes in our re-eclampsia patients. There is a reflex hammer (even this is optional; I am often in the habit of doing it with my stethoscope), so I asked for it. Her patellar reflexes were absent. (Brachial and biceps about 1/4)

Several of my Haitian colleagues did not like my technique for testing patellar reflexes in a supine patient. I said, there are several possible techniques. They said my technique was wrong. I said again,
there are several possibilities. They said, that is not one of them. I said, I suppose the neurologists I studied with at home were wrong?

They said, yes, it seems.

It is not a good way to start the day, being insulted. Actually, there is no time of day when I feel good about being told I am a bad doctor.

Later in the morning, someone came to tell me that there was a cardiac arrest in the delivery room. I arrived to find a resuscitation underway: patient already intubated, gynecologist performing chest
compressions. Shortly thereafter, efforts were discontinued.

The patient had apparently been in labour but well. Her blood pressure was normal. She did not fall into our admission criteria, which have been tightened in order to accept only the sickest patients. (Other patients certainly need care, but can be cared for in other centres). As she was getting into the car to be transferred, she felt the urge to push, and so was brought to the delivery room. There, she had a seizure. Then pushed out a stillborn baby, and a placenta that clearly had abrupted. Then she had a cardiac arrest from which she never awoke.

It is a strange case. My theory – not having yet examined the chart – is normotensive eclampsia, abruptio placenta. The cause of the cardiac arrest: possibly hemorrhage from the abruption, possibly amniotic fluid embolus, possibly something else.

It was so sudden. The staff was shaken. The family, of course, was devastated. The walls shook with their grief. Their screams went on for a long time. I was thankful that the psychosocial team was so near at hand.

And immediately after, one of the gynecologists came to find me. He looked extremely upset. What should we do? he said. There was a patient about to be operated, with severe pre-eclampsia and two
previous caesarians. She is already anemic, with a hemoglobin of 5.4g/dL. They were about to start a transfusion, but, it turns out, she’s a Jehovah’s Witness and so refused the blood transfusion.

I discussed with the anesthetist and the gynecologist. The patient understands the risk of death without the transfusion. She accepts the surgery. We agreed that it would be good to discuss again with patient and with her family, to know if they all agree, or at least have understood the wishes of the patient. We decided to document the refusal of transfusion separately from the consent for surgery. The doctors asked for the psychosocial team to help with the counselling.

The Brazilian psychologist told me later: everything was arranged. The family agrees: no transfusion. Members of the church came also. The patient would have her operation.

This evening, as I left, I found the anaesthetist, and the surgeon. I asked how the patient was doing. Poorly, they said: she has a systolic blood pressure of 60. They were bringing the husband upstairs to see her.